Advances in Posterior Cruciate Ligament Reconstruction

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Current advances in posterior cruciate ligament (PCL) reconstruction have achieved excellent clinical and function-al outcomes.1-8 Anatomy, cadaver sec-tioning studies, biomechanical studies, and clinical outcome data are reviewed in this chapter. Current controversies, including transtibial versus inlay, auto-graft versus allograft, and single-bundle versus double-bundle reconstructions,

are highlighted. Novel surgical tech-niques, including the all- inside PCL reconstruction, are discussed.

AnatomyThe anatomy of the PCL has been recently revisited and highlighted by Kennedy et al.9 The PCL complex is divided into the anterolateral bundle, the posteromedial bundle, and the

meniscal femoral ligaments. The menis-cal femoral ligaments are divided into the anterior meniscofemoral ligament (otherwise known as the ligament of Humphrey) and the posteromedial fem-oral ligament (otherwise known as the ligament of Wrisberg). The anterolateral bundle is primarily responsible for re-straining posterior tibial translation at 90° of knee fl exion, and this bundle has been traditionally reconstructed in single-bundle reconstructions. The posteromedial bundle acts as a re-straint to posterior tibial translation at approximately 30° of knee fl exion, and this bundle is reconstructed in double- bundle reconstructions. The femoral and tibial insertions are shown in Fig-ures 1 and 2.

A key element in the anatomy of the PCL is the insertion at the base of the tibial PCL facet. Understanding this anatomy is essential to restoring normal PCL function during reconstruction. Whether this insertion site is obtained by using a transtibial approach ar-throscopically or an open inlay approach through a posteromedial incision, an

Advances in Posterior Cruciate Ligament Reconstruction

Bruce A. Levy, MDGregory C. Fanelli, MD

Mark D. Miller, MDMichael J. Stuart, MD

SYMPOSIUM

Dr. Levy or an immediate family member has received royalties from VOT Solutions and Arthrex; serves as a paid con-sultant to or is an employee of Arthrex; has received research or institutional support from Arthrex, Biomet, and Stryker; and serves as a board member, owner, offi cer, or committee member of the Arthroscopy Association of North America (representative to the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine) and Knee Surgery Sports Traumatolog y and Arthroscopy; and is a deputy editor for Clinical Orthopedics and Related Research. Dr. Fanelli or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Biomet and CONMED Linvatec. Dr. Miller or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Orthopaedic Society for Sports Medicine and Miller Orthopaedic Review Enterprises. Dr. Stuart or an immediate family member has received royalties from Arthrex; serves as a paid consultant to or is an employee of Arthrex; and has received research or institutional support from Stryker.

AbstractCurrent advances in posterior cruciate ligament reconstruction have led to excellent clinical and functional outcomes. It is helpful to review anatomy, cadaver sectioning studies, biome-chanical studies, clinical outcome data, and novel surgical techniques for posterior cruciate ligament reconstruction, including all-inside reconstructions. Surgeons also should be aware of current controversies regarding transtibial versus inlay, autograft versus allograft, and single-bundle versus double-bundle reconstructions.

Instr Course Lect 2015;64:543–554.

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544 © 2015 AAOS Instructional Course Lectures, Volume 64

understanding of the insertion sites of this particular attachment site is criti-cal for a successful PCL reconstruction. More recently, the anatomy of the in-tercondylar notch and its reference to the PCL bundles were delineated. The top of the notch is referred to as the intercondylar notch apex, and several other points are described. The troch-lear point and the medial arch point are the boundaries of the anterolateral bundle and also are used as reference marks for the posteromedial bundle. Also, there is the so-called arch of the cartilage and an area referred to as the straight cartilage, which delineates areas of the anterolateral and posteromedial bundles on the medial femoral condylar

wall (Figure 3). As a general rule, the PCL is a much larger ligament than the anterior cruciate ligament (ACL), with an average dimension of 33 × 13 mm. Because it has a crescent-shaped inser-tion on the femur, it is often diffi cult to fi nd the so-called isometric point when performing single-bundle PCL reconstructions.

Surgical Technique OptionsThe two traditional ways of recon-structing the PCL are the open inlay and the arthroscopic transtibial tun-nel techniques. Other options include single- bundle (anterolateral bundle) and double-bundle (anterolateral and posteromedial bundle) reconstructions.

The graft choices include a wide variety of autograft and allograft options.

Open Inlay Versus Arthroscopic Transtibial ReconstructionsBiomechanical EvidenceMcAllister et al10 performed a cadaver cyclic loading study and compared tran-stibial tunnel and tibial inlay PCL graft reconstructions. The reconstructions were brought through cyclic loading to failure. The authors found no important advantage of one technique versus the other.

Clinical EvidenceMay et al11 performed a systematic clin-ical review of the literature comparing transtibial with inlay PCL reconstruc-tion. Similar to the biomechanical data, the authors reported no important ad-vantage of one technique versus the other.

Single- Versus Double-bundle ReconstructionsBiomechanical EvidenceMarkolf et al12 performed a cadaver study of single-bundle versus dou-ble-bundle reconstructions and found that the single-bundle anterolateral PCL reconstruction graft best reproduced normal PCL force profi les, whereas the double-bundle reconstruction slightly reduced laxity at 0° to 30°. Whiddon et al13 performed a cadaver study com-paring single- versus double-bundle reconstructions using an open inlay PCL reconstruction cadaver model. The authors looked at 10 cadaver knees that used bone-patellar tendon-bone al-lografts and tested these knees in a sim-ilar way as the knees would be clinically tested (that is, they used the posterior drawer test, the dial test, and posterior

Illustration of the anterior view of a right knee fl exed to 90° with the posterior cruciate ligament (PCL) intact, demonstrating the characteristic morphology of the cartilage margin of the femoral intercondylar notch. The illustration also shows the trochlear point, the medial arch point, and the pos-terior point, as well as the intercondylar notch apex and the trochlear groove. ACL = anterior cruciate ligament, ALB = anterolateral bundle, aMFL = anterior meniscofemoral ligament, PMB = posteromedial bundle. (Reproduced with permission from Anderson, CJ, Connor G, Ziegler, MD, et al: Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the pos-terior cruciate ligament. J Bone Joint Surg Am 2012;94:1936-1945.)

Figure 1

Advances in Posterior Cruciate Ligament Reconstruction Chapter 48


stress radiography). The knees were tested intact and then retested after se-quential resection of both the PCL and the posterolateral corner structures. The authors found that if they resected the PCL and the posterolateral corner but did not restore the posterolateral corner structures, the double- bundle PCL re-construction had better rota tional stabil-ity. However, if they sectioned the PCL and the posterolateral corner and then reconstructed the posterolateral corner, they found no difference between the single- and double-bundle techniques.

Clinical EvidenceSingle-bundle versus double-bundle re-constructions were compared in a recent systematic clinical review by Kohen and Sekiya.8 The authors stated the follow-ing: “The superiority of single-bundle or double-bundle posterior cruciate ligament reconstruction remains un-certain.” In a comparative study by Wang et al,14 the authors performed a prospective study of 35 patients, 19 with single-bundle reconstructions and 16 with double-bundle reconstructions. They used hamstring autografts and followed this group of patients for 2 years and found no signifi cant differ-ences in functional scores, ligament lax-ity, and radiographic changes. Fanelli et al15 reported on a series of 90 con-secutive PCL reconstructions, where the fi rst 45 were performed using a sin-gle-bundle technique and the next 45 were performed using a double-bundle technique. Each reconstruction used a transtibial approach and a fresh- frozen allograft. Follow-up was between 24 and 72 months. When comparing stress radiography, KT-1000 arthrom-eter (MEDmetric) results, the Tegner Lysholm Knee Scoring Scale, and Hos-pital for Special Surgery functional knee

scores, the authors were unable to fi nd any signifi cant differences between the two groups.

Autograft Versus AllograftHudgens et al16 also performed a sys-tematic review comparing allograft ver-sus autograft in PCL reconstruction and found satisfactory clinical and func-tional results from both graft types. Other authors have reported excellent long-term outcomes with the transtibial

technique, the open inlay technique, autograft reconstruction, allograft re-construction, and single-bundle and double-bundle PCL reconstructions.1-8 As with any surgical technique, under-standing the anatomy of the PCL is the fi rst step in successful surgery.

Transtibial Tunnel Surgical TechniqueThis chapter’s authors prefer an Achil-les tendon allograft for single-bundle

Illustration of the posterior aspect of a right knee with the poste-rior cruciate ligament (PCL) intact, demonstrating the fi ber orientation. ALB = anterolateral bundle, PMB = posteromedial bundle, pMFL = posterior menis-cofemoral ligament. (Reproduced with permission from Anderson, CJ, Connor G, Ziegler, MD, et al: Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the posterior cruciate ligament. J Bone Joint Surg Am 2012;94:1936-1945.)

Figure 2

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PCL reconstructions, and Achilles ten-don and tibialis anterior allografts for double-bundle PCL reconstructions.17 Allograft tissue is prepared, and arthro-scopic instruments are placed with the infl ow in the superior lateral portal, the arthroscope in the inferior lateral patellar portal, and instruments in the inferior medial patellar portal. An ac-cessory extracapsular, extra-articular posteromedial safety incision is used to protect the neurovascular structures and confi rm the accuracy of tibial tun-nel placement (Figure 4). The incision is made along the posteromedial tibial crest at 4 to 5 cm distal to the joint line. Dissection is carried down to the fas-cia, and a plane is created between the medial head of the gastrocnemius and the semimembranosus tendon. Blunt fi nger dissection is then used to sweep

anterior to the gastrocnemius tendon, allowing extra-articular palpation of the mammillary bodies on either side of the PCL facet.

To prepare for a combined PCL-ACL reconstruction, notch preparation is performed fi rst and consists of ACL and PCL stump débridement, bone re-moval, and contouring of the medial and lateral walls and the roof of the in-tercondylar notch. Specially designed 90° curets and rasps placed through the notch to the posterior aspect of the tibia are used to elevate the capsule and clearly identify the PCL-tibial footprint.

The arm of the PCL-ACL guide is inserted through the inferior medi-al patellar portal to begin creation of the PCL-tibial tunnel. The tip of the guide is positioned at the inferior lateral aspect of the PCL anatomic insertion

site. The bullet portion of the guide contacts the anteromedial surface of the proximal tibia at a point midway between the posteromedial border of the tibia and the anterior tibial crest, approximately 1 cm below the tibial tu-bercle. This provides an angle of graft orientation such that the graft will turn two very smooth 45° angles on the pos-terior aspect of the tibia and will not have an acute 90°-angle turn that may cause pressure necrosis on the graft. The tip of the guide, in the posterior aspect of the tibia, is confi rmed with the surgeon’s fi nger through the extra-capsular, extra-articular posteromedial safety incision. Intraoperative AP and lateral radiographs also may be used. As a double safety check, the surgeon uses his or her fi nger to confi rm the position of the guidewire through the posterior medial safety incision.

An appropriately sized, standard cannulated reamer is used to create the tibial tunnel. The surgeon uses his or her fi nger placed through the extracap-sular, extra-articular posteromedial in-cision to monitor the position of the guidewire. The drill is advanced until it comes to the posterior cortex of the tibia. The chuck is disengaged from the drill, and completion of the tibial tunnel is performed by hand. This provides an additional margin of safety for comple-tion of the tibial tunnel.

The PCL single- or double-bundle femoral tunnels are made from the inside out. Inserting an appropriately sized, double-bundle aimer through a low anterior lateral patellar arthro-scopic portal creates the PCL antero-lateral bundle femoral tunnel. The double-bundle aimer is positioned di-rectly on the footprint of the femoral anterolateral bundle PCL insertion site. The appropriately sized guidewire is

Anterior photograph of a right knee fl exed to 90° with a probe (from posterior) separating the anterolateral bundle (ALB) and the posterome-dial bundle (PMB) of the posterior cruciate ligament and demonstrating the landmarks surrounding the trochlear point and the medial arch point along the cartilage margin of the femoral intercondylar notch. (Reproduced with permission from Anderson, CJ, Connor G, Ziegler, MD, et al: Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the pos-terior cruciate ligament. J Bone Joint Surg Am 2012;94:1936-1945.)

Figure 3



drilled through the aimer, through the bone, and out a small skin incision. The double-bundle aimer is removed, and an acorn reamer is used to endoscopically drill from inside out the anterolateral PCL femoral tunnel. When performing a double-bundle double femoral tunnel PCL reconstruction, the same process is repeated for the posteromedial bundle of the PCL. There should be at least 5 mm of bone between the two PCL femoral tunnels.

The cyclic dynamic method of graft tensioning is used to tension the PCL and ACL grafts (Figure 5). During this surgical technique, the PCL and/or ACL grafts are secured on the femoral side fi rst with the surgeon’s pre-ferred fi xation method. The technique described is a tibial-sided tensioning method. Polyethylene ligament fi xa-tion buttons are used for cortical sus-pensory fi xation, and aperture opening interference fi xation with bioabsorbable interference screws are used for femoral side PCL and ACL fi xation. In com-bined PCL-ACL reconstructions, the PCL graft is tensioned fi rst, followed by fi nal PCL graft tibial fi xation. ACL graft tensioning and fi xation follows that of the PCL.

The tensioning boot is applied to the foot and the leg of the surgical limb, and tension is placed on the PCL graft(s) distally using a device such as the Biomet graft-tensioning boot (Biomet). Tension is gradually applied with the knee in 0° of fl exion (full extension), thus reducing the tibia on the femur. This restores the anatomic tibial step-off. The knee is cycled through a full range of motion multiple times to allow pretensioning and settling of the graft. The process is repeated until there is no further change on the torque setting of the graft tensioner with the knee at 0°

of fl exion. When no further changes or adjustments are necessary in the tension applied to the graft, the knee is placed in 70° to 90° of fl exion, and fi xation is achieved on the tibial side of the PCL graft with a bioabsorbable interference screw for interference fi t fi xation and backup cortical suspensory fi xation with a bicortical screw and a spiked liga-ment washer or a polyethylene ligament fi xation button.

It is very important to use primary and backup fi xation. During PCL-ACL reconstruction, primary aperture fi xa-tion is achieved with bioabsorbable in-terference screws, and backup fi xation is performed with a screw and a spiked ligament washer and ligament fi xation buttons. Secure fi xation is critical to the success of this surgical procedure. In

the experience of this chapter’s authors, mechanical tensioning of the cruciate ligaments at 0° of knee fl exion and res-toration of the normal anatomic tibial step-off at 70° to 90° of fl exion has pro-vided the most reproducible method of establishing the neutral point of the tibial-femoral relationship. Full range of motion is confi rmed on the operating table to ensure the knee is not “cap-tured” by the reconstruction.

Tibial Inlay Surgical Technique Berg18 fi rst introduced a tibial inlay technique for PCL reconstruction in 1995.18 This chapter’s authors adapted this technique shortly after its publica-tion and have modifi ed it over the years. The Berg technique has been combined

Intraoperative photograph of the transtibial tunnel surgical tech-nique. The 2-cm extracapsular extra-articular posteromedial safety incision allows the surgeon to position his or her fi nger posterior to the capsule of the knee joint and anterior to the medial head of the gastrocnemius and the neu-rovascular structures. This enables the surgeon to protect the neurovascular structures, monitor instruments working in the posterior aspect of the knee, confi rm the accuracy of the posterior cruciate ligament (PCL) reconstruction tibial tunnel, and facilitate the fl ow of the surgical procedure. The PCL rasp ele-vator is shown in use. (Reproduced with permission from Fanelli GC, Giannotti B, Edson CJ: Current concepts review: The posterior cruciate ligament. Arthroscopic evaluation and treatment. Arthroscopy 1994;10[6]:673-688.)

Figure 4

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with the posterior approach described previously by Burks and Shaffer,19 and it has subsequently been modifi ed as described later in this chapter.

The advantage of the inlay technique is that it eliminates graft abrasion and attrition associated with the traditional transtibial PCL technique.20 The PCL

graft can be fi xed directly into a trough at its tibial origin, and an anatomic PCL reconstruction can be accomplished. The approach is safe because the pop-liteal artery is retracted by the medial head of the gastrocnemius and is well outside the surgical fi eld.21,22 This chap-ter’s authors also have eliminated the problems associated with reposition-ing the patient during this procedure by placing the patient in the lateral decubitus position and simply rotating the leg at the hip to access the front of the knee.23

Patient SelectionIn the experience of this chapter’s au-thors, PCL injuries are rarely isolated. They commonly occur as a result of a motor vehicle crash (the so-called dashboard injury) and usually involve disruption of the posterolateral corner. The posterior drawer test, the preferred test for PCL injuries, can be quantifi ed with stress radiographs. Research has shown that isolated PCL injuries have a side-to-side difference of 10 mm or less on stress radiographs, but a combined PCL- and posterolateral corner–injured knee has a side-to-side difference of 20 mm or more.24 This chapter’s au-thors address these injuries within the fi rst 2 weeks and repair and/or recon-struct all the injured structures at that time. The repair and reconstruction of the posterolateral corner yields the best long-term outcomes.25

Patient PositioningAs indicated earlier, after the comple-tion of an examination under anes-thesia, the patient is positioned in the lateral decubitus position with the in-jured leg up (Figure 6). It is important to pad the contralateral leg and all other extremities and use an axillary roll. A

Intraoperative photograph of the mechanical graft tensioning boot, which is used to tension both the posterior cruciate ligament (PCL) and the anterior cruciate ligament (ACL) reconstructions. It aids in reducing the tibia on the femur, pretensioning the PCL and ACL grafts, and maintaining reduc-tion during cycling and cruciate ligament graft fi xation.

Figure 5

Intraoperative photograph of a patient in the lateral decubitus position. Note that the surgical (right) leg is up and the nonoperative leg is well padded and down. A bean bag positioner is used, and the surgical leg can be rotated when necessary.

Figure 6



bean bag is used to hold the patient in position. This chapter’s authors use a tourniquet but do not use a leg holder on the thigh. The surgical foot and leg is placed into a bracketed leg holder, which helps position the leg during the anterior portions of the procedure (Figure 7).

Surgical TechniqueFor patients with an acute combined injury (within 2 weeks), this chapter’s authors usually begin with an egress incision in the center of the planned corner incision to prevent iatrogenic compartment syndrome (Figure 8). A generous (11- to 12-mm) central one-third bone-patellar tendon-bone graft is then harvested and prepared on a back table. A tibial portion of the graft is preferred for the tibial inlay; it is made rectangular and approximately 20 to 25 mm in length. The patellar portion of the graft is “bulleted” and is fash-ioned to be approximately 18 mm in length (Figure 9). This smaller size facilitates easier graft passage into the femoral tunnel. The graft is placed un-der tension on a graft board during the next portion of the procedure.

Arthroscopy is then performed, and the injured PCL is débrided with a basket and a shaver. If there are intact fi bers (including meniscofemoral liga-ments), these should be retained when-ever possible. Note that ACL laxity may be normal, which will resolve when an anterior drawer test is applied.26

The femoral tunnel is drilled from the outside in. A subvastus approach is made through an incision in the Langer lines, and a guide is used to place a 0.094-inch (3/32) guide pin high in the notch (at approximately the 1:30 clock position for a right knee) and 6 to 8 mm from the articular surface (Figure 10).

The outside-in approach reduces the amount of graft bend in the femoral tunnel (the critical corner).27-29 The tunnel is overdrilled with the appro-priate cannulated drill, and bone graft from the drill fl utes is collected for later placement in the patellar harvest site. The posterior aspect of the tun-nel is rasped to reduce graft abrasion. A looped 18-gauge Luque wire is then positioned arthroscopically through the tunnel and into the posterior aspect of the knee.

The leg is then placed on a Mayo stand and preparation is done for the tibial inlay approach. The surgeon sits on a stool and uses a headlight to di-rectly approach the popliteal fossa. An incision is made in the popliteal crease, and the gastrocnemius fascia is incised. A hockey stick incision is made in the fascia (but not in the skin as originally described by Burks and Shaffer19)

(Figure 11). The medial head of the gastrocnemius is identifi ed and bluntly mobilized. Note that the tendinous portion of this large muscle is on the deep surface. The medial head of the gastrocnemius is very mobile and can be retracted laterally, past the midline. This muscle can be held in place with 0.094-inch pins that can be bent and used as retractors. The muscle belly of the popliteus is identifi ed, and a pos-terior arthrotomy is made at its supe-rior border. This can be enlarged with Mayo scissors, and the preplaced Luque wire is retrieved (Figure 12). The PCL fossa is palpated, and an electrocautery, a rongeur, and a burr are used to create a trough that matches the dimensions

Intraoperative photo-graph of a patient’s left leg posi-tioned in a bracketed leg holder.

Figure 7

Intraoperative pho-tograph of the egress incision. This incision is made prior to arthroscopy to avoid iatrogenic compartment syndrome. Note that the medial collateral ligament was entrapped in the joint. Often, the joint is exposed quite easily after only a superfi cial dissection.

Figure 8

Photograph of a bone-patellar tendon-bone autograft. The rect-angular tibial portion of the graft (arrow) is used for the tibial inlay, and the bulleted portion (arrowhead) is for the femoral side.

Figure 9

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of the graft. The graft is then brought up to the surgical fi eld and secured to the drapes (as a safety net). The patellar

portion of the graft is pulled into the knee (and hopefully directly into the femoral tunnel), and the tibial portion is

inlayed into the trough. The graft is se-cured with 4.5-mm cannulated screws. These screws are serially drilled, mea-sured, and then placed to secure the graft in the trough. It is helpful to clamp the guidewires at the anterior portion of the tibia before drilling to help with screw placement.

The knee is then placed into the bracketed knee holder, and the graft is arthroscopically visualized. If the pa-tellar bone block was not delivered into the femoral tunnel, then it is passed at this point. Sometimes it is necessary to toggle the graft with a right angle clamp to facilitate passage. After it is in the tunnel, the knee is cycled to eliminate any kinking, and the graft is fi xed in the femur with a 9 × 20-mm metal in-terference screw. Note that an anterior drawer force is place on the tibia while the graft is fi xed. A Shantz pin with a handle from the external fi xation set is useful for this purpose (Figure 13). The fi nal graft position is examined arthroscopically and also carefully ex-amined on the table, and the remaining ligament repairs and/or reconstructions are completed before standard closure.

Intraoperative photograph of arthroscopy being performed with the leg externally rotated and in a bracketed knee holder. Note that the position of the femoral pin is checked arthroscopically.

Figure 10

Intraoperative photograph of the inlay approach. The medial head of the gastrocnemius is retracted with Steinmann pins and the Luque wire is retrieved from the knee for later graft passage.

Figure 11

Intraoperative photograph showing the graft inlayed into a trough that was burred into the back of the tibia. Fixation of the graft with posterior to anterior placed screws is accomplished prior to graft passage. PCL = posterior cruciate ligament.

Figure 12



All-Inside PCL ReconstructionThe arthroscopic transtibial, open in-lay, and arthroscopic inlay techniques provide reliable clinical and func tional outcomes.1-8 Another option is the all-inside technique that uses either autograft or allograft to reconstruct the PCL, using sockets and suspensory fi xation in both the tibia and the femur.

The open inlay technique requires a separate posteromedial incision to cre-ate a bone trough at the base of the PCL facet. The bone block of an autograft or an allograft is inserted into the tibial trough and secured with cancellous or bicortical screws. The main advantage of this technique is to avoid the “killer turn” that has been described with a transtibial tunnel.10 The arthroscopic transtibial tunnel technique is less inva-sive but requires a very long tibial tun-nel, and graft abrasion can potentially occur along the posterior tibial margin.

This concern has led to the de-velopment of the arthroscopic inlay technique. Campbell et al5 fi rst re-ported on the all-arthroscopic PCL double-bundle technique with bone- patellar tendon-bone allograft to

achieve bony fi xation on both the tibial and femoral sides. A custom tibial guide and a retrograde drilling system create the tibial tunnel. The authors argued that this procedure eliminates the killer turn of the transtibial tunnel technique and the large posteromedial incision of the open inlay.

Salata and Sekiya30 published a simi-lar all-arthroscopic PCL reconstruction technique using a fresh-frozen Achilles tendon allograft. Similar to the Camp-bell et al5 method, the tibial socket is made at the PCL insertion site, using a guide and a retrograde drilling system. A graft with a single bone block is in-serted arthroscopically into the tibial socket and secured with suspensory fi x-ation. Arthroscopic passage of the bone block and tibial socket docking can be technically challenging. The short-term outcome data are promising, but com-plications have been reported, including bone block fracture and nonunion.

A novel all-inside technique uses soft-tissue autograft or allograft with tibial and femoral sockets and suspen-sory fi xation. Although clinical data are not currently available, this method has all the advantages of the inlay and arthroscopic techniques but avoids the posteromedial incision, bone block passage through portals, and the killer turn.

Surgical TechniquePatient PositioningThe patient is positioned supine on the operating table, perioperative an-tibiotics are administered, and general anesthesia is induced. Both knees are examined to assess the integrity of the cruciate and collateral ligaments. The surgical leg is prepped and draped in standard fashion, and a tourniquet is placed high on the thigh.

Graft PreparationA tibialis anterior or a peroneus lon-gus allograft with a minimum length of 36 cm is prepared using a graft prepara-tion board. Suspensory fi xation is used on both the femoral and the tibial sides of the graft. Two circumferential heavy nonabsorbable sutures incorporating all four tendon strands are placed at 1 cm and 2.5 cm from each end of the graft. These sutures create a coupled, four-stranded construct with a total length of 95 to 100 mm. The graft is the placed on the board under 20 mm of tension (Figure 14).

Arthroscopic All-Inside ReconstructionStandard superomedial, inferomedial, inferolateral, and accessory inferome-dial portals are placed. A diagnostic arthroscopy documents all osseous, chondral, meniscal, and ligamentous

Intraoperative photograph of a Shantz pin placed in the proximal tibia during repair of a posterior cruciate ligament injury. An anterior drawer test is performed during fi nal femoral fi xation.

Figure 13 Photograph of a prepared tibialis anterior allograft under tension on a graft preparation board for posterior cruciate ligament reconstruction. Figure 14

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pathology. After a thorough assessment of the knee, an accessory posteromedial portal is created to release the tibial footprint of the native PCL in between the mammillary bodies. The PCL guide is then placed through the anterome-dial portal and positioned proximal to the distal edge of the PCL facet. Flu-oroscopy or arthroscopic visualization through the posteromedial portal is used to confi rm proper guide place-ment. The drill sleeve is placed fl ush on the tibia, and the total intraosseous distance is measured. A guidewire is then drilled, and proper placement can be confi rmed with fl uoroscopy. With the guide in position, the tibial socket

is reamed using a retrograde reaming device to a depth of 35 to 40 mm. The PCL guide acts to protect the neurovas-cular bundle during guidewire place-ment and reaming.

After clearing out the tibial socket, a passing suture is then placed through the drill sleeve into the joint and re-trieved from the inferomedial portal.

Femoral PreparationThe preferred technique of this chap-ter’s authors is an inside-out, single anterolateral bundle reconstruction. PCL fi bers are débrided from the lat-eral wall of the medial femoral condyle, and the anterolateral bundle footprint

is retained to aid femoral socket place-ment. A spade tip guidewire centered on the anatomic footprint of the antero-lateral bundle is drilled out the medial cortex of the femur. The intraosseous distance is measured from the guide-wire for later graft passage. An 11- or 12-mm reamer placed over the guide-wire is used to create the femoral socket to a minimum depth of 25 mm. A pass-ing suture is then pulled into the joint and retrieved from the inferomedial portal for later graft passage.

Completing the ReconstructionThe sutures from both the femoral and tibial sockets are pulled through the accessory inferolateral portal for graft passage (Figure 15). The tibial end of the graft is inserted fi rst into the joint and deep into the tibial socket. With tension on the graft, the femoral side is inserted into the femoral socket. The femoral suspensory device is brought through the medial cortex while main-taining countertension at the femoral tip of the graft, and the button is de-ployed. The sutures are sequentially ten-sioned to insert the graft into the socket to a depth of approximately 20 mm.

Tension is placed on the tibial side of the graft with the knee fl exed to 90°. The arthroscope is placed in the posteromedial portal to verify a min-imum of 20 mm of tibial graft within the socket (Figure 16). If there is ex-cess graft in the tibial socket, additional graft is pulled into the femoral socket. The 40-mm deep tibial socket ensures that the graft can be tensioned without bottoming out.

Final graft tensioning and fi xation are performed with the knee fl exed to 80°. A button is attached to the tibial sutures, and the sutures are sequential-ly tightened to inset the graft into the

Intraoperative arthroscopic images of passing sutures within the tibial (A) and femoral (B) sockets. The view here is from the anteromedial portal.

Figure 15

Intraoperative arthroscopic images with the femoral side of the graft in position. A, At least 20 mm of graft should be seated within the femoral socket. The purple marking represents 25 mm from the end of the graft. B, View from the anterolateral portal. Note the intact anterior cruciate ligament.

Figure 16



tibial socket. Alternate tensioning of both femoral and tibial sutures maxi-mizes graft tension. Backup fi xation on the tibial side is achieved by securing the graft sutures with an anchor or a screw-post construct. Final AP and lat-eral radiographs of this procedure are shown in Figure 17.

SummaryControversies regarding the ideal PCL reconstruction technique continue to be debated among sports medicine sur-geons. Clinical outcome studies have shown satisfactory results regardless of graft choice, surgical technique, fi xation strategies, and rehabilitation protocols.

Advances in PCL reconstruction have led to the development of less in-vasive procedures. The all-inside tech-nique is an arthroscopic method that uses tibial and femoral sockets, extra-cortical fi xation, and a high strength graft. The early results are promising, but research is necessary to document the clinical outcomes. Multicenter pro-spective trials are currently underway that will hopefully guide future treat-ment decisions.

References 1. Cooper DE, Stewart D: Posterior

cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fi xation: 2- to 10-year follow-up. Am J Sports Med 2004;32(2):346-360.

2. Yoon KH, Bae DK, Song SJ, Lim CT: Arthroscopic double-bundle augmentation of posterior cruciate ligament using split Achilles allograft. Arthroscopy 2005;21(12):1436-1442.

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Final AP (A) and lateral (B) postoperative radiographs of posterior cruciate ligament reconstruction using the all-inside technique. The patient also underwent posterolateral corner reconstruction.

Figure 17

Sports Medicine


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Advances in Posterior Cruciate Ligament Reconstruction

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